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IN THE NAME OF GOD

Three cases of Behcet`s disease with vascular involvement. IN THE NAME OF GOD. Gholamrezapoor , MD, resident of internal medicine & Sasan Fallahi , MD, rheumatologist, Kerman University of Medical Sciences. CASE PRESENTATION. FIRST CASE. A 48 years old female. HISTORY. Chief complaint

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IN THE NAME OF GOD

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  1. Three cases of Behcet`s disease with vascular involvement IN THE NAME OF GOD Gholamrezapoor, MD, resident of internal medicine & SasanFallahi, MD, rheumatologist, Kerman University of Medical Sciences

  2. CASE PRESENTATION

  3. FIRST CASE A 48 years old female

  4. HISTORY • Chief complaint Pain and swelling of the left lower limb • Present illness Patient’s problem has been started from four weeks ago, initially she had pain and subsequently swelling of the left lower limb. Swelling appeared initially in distal side of leg and then extended to proximal side of the left thigh. She also had history of fever, especially at the evening. No dyspnea, chest pain and hemoptysis.

  5. HISTORY • Past History she did not have any previous history of known illness, except admission for PID, 7 years ago. She also, had an abortion. No history of recent surgery, trauma, bed ridden or traveling. She used Prednisolone(5mg daily),Omeprazol, Doxepin and Loratadin since 4 weeks ago, but she did not used OCP.

  6. HISTORY • Family History There was no significant point. • Personal and Social History She was not smoker and opium addict.

  7. HISTORY • Review of Systems Oral painful lesions • Since 8 years ago • Interval 20 days • Duration 10-15 days • At the time of physical examination, the lesion was present. Genital painful lesions • Since 4 years ago • Interval several months • Duration 5-7 days • At the time of physical examination, the lesion was not present. Dysuria • When genital lesion was present

  8. HISTORY • Review of Systems Red eye, tearingand Painin left eye since 20 years ago intermittently. No history of visual loss Skin lesion in both lower limbs since 15 days ago No history of headache and seizure No history of GI problems such as abdominal pain or diarrhea No history of arthralgia or arthritis

  9. PHYSICAL EXAMINATION • General Survey Patient is a middle age female, awake and oriented, without any distress, she was thin and pale. • Vital Signs PR:80 RR:15 BP:90/60 AxilaryT:37

  10. PHYSICAL EXAMINATION • Head & Neck -Mild conjunctivitis and tearing in left eye was noted(red eye). -Aphthous lesions in right and left side of tongue were noted -Trachea and thyroid were normal - No adenopathy • Chest & Cardiac & Axillary NL • Abdomen Prominent veins were visible in epigastric zone, with flow from down to up. There was no distention, tenderness, hepatomegaly, splenomegaly and ascites.

  11. PHYSICAL EXAMINATION • Upper extremities -No skin lesion -Bilateral radial arteries pulsation were normal and symmetric . -Active and passive motion of joints were normal. Force of proximal and distal muscles were near to normal for her sex and age

  12. PHYSICAL EXAMINATION • Lower extremities -Swelling and pitting edema in left lower limb, specially in foot, ankle and distal side of leg -Size difference between circumference of two legs was about 2.5cm. -Red brownish colored nodule with tenderness(1.5 * 1.5 cm ) on lateral side and anterior surface of the left leg compatible with erythema nodosum -Dorsalispedis and posterior tibialis arteries pulsation in left side were palpable but weaker than right side. Active and passive motion of joints were normal. Force of proximal and distal muscles were near to normal.

  13. DUPPLER SONOGRAPHY • Thrombosis in CFV and SFV were noted. • Venous thrombosis was extended to the left iliac vein and IVC. • SMA, SMV, Portal vein and hepatic arteries were normal.

  14. DIANOSIS DVT

  15. LABORATORY TEST • CBC WBC:7500 RBC:3790000 HG:9.2 HCT:31.3 MCV:82.6 MCH:24.3 MCHC:24.4 Plat:360000 ESR:104 CRP:+3 RF: Neg

  16. LABORATORY TEST • Biochemistry BS:86 Urea:15 Creat:0.89 AST:18 ALT:12 Al Ph:255 Bil Total:0.6 Bil Direct:0.16 LDH:435 • Electrolyte Na:135 K:3.9 Ca:8.5 P:4.5 • Coagulative PTT:41 PT:15 INR:1

  17. LABORATORY TEST • PBS Hypochromic:+1 Anisocytosis:Mild Poychilocytosis:+1 Ovalucytosis:Mild Teardrop:Mild Helmet:Mild • Urine analysis SG:1015 PH:7 Others: NL

  18. ECHOCARDIOGRAPHY • EF:60% • PAP:NL • There was no abnormal finding.

  19. ABDOMINOPELVICE SONOGRAPHY • Liver, biliary tract, pancreas and urinary tract were normal

  20. GYNECOLOGICAL CONSULT • No aphthous, active lesion or scar in genital area

  21. OPHTHALMOLOGICAL CONSULT • There was naso-lacrimal duct stenosis in left eye. • No evidence of uveitis or retinal vasculitis

  22. SECOND CASE A 36 years old male

  23. HISTORY • Chief complaint Pain and swelling of the right lower limb since two weeks ago • Present illness -Swelling has been appeared initially in right foot and then extended to the right legand thigh. -No fever, dyspnea, chest pain and hemoptysis

  24. HISTORY • Past History -known case of DM since six months, ago -No history of recent surgery, trauma or bed rest, but he had a trip by bus , 45 days ago.

  25. HISTORY • Family History No significant point. • Personal and Social History No smoking and opium addiction

  26. HISTORY • Review of Systems Oral painful lesions • The first time appeared at 1375 and continued for 2 weeks and then disappeared for 5 years • Further started from 1380 • Interval 20 days • Duration about 15 days • At the time of physical examination, the lesion was present. Genital painful lesions • The first time appeared at 1380 And reoccurred several times . • Duration 3-5 days • At the time of physical examination, there was no lesion or scar.

  27. HISTORY • Review of Systems -45 days, ago a few skin pustular lesions appeared on right leg. only two small brownish papule remained. -No history of erythema nodosum -Swelling of right testis one month, ago -No history of visual loss, red eye and ocular pain -No history of headache and seizure -No history of GI problems such as abdominal pain or diarrhea -No history of arthralgia or arthritis

  28. PHYSICAL EXAMINATION Patient is a young male, awake and oriented, without any distress. • Vital Signs PR:84 RR:14 BP:120/80 AxillaryT:37.4

  29. PHYSICAL EXAMINATION • Head & Neck -An aphthouslesion in anterior side of tongue was noted. -Trachea and thyroid were normal. -No adenopathy • Chest & Cardiac & Axillary NL • Abdomen -No distention, tenderness, hepatomegaly, splenomegaly and ascites

  30. PHYSICAL EXAMINATION • Upper extremities -No skin lesion -Bilateral radial arteries pulsation were normal and symmetric. -Active and passive motion of joints were normal. -Force of proximal and distal muscles were normal.

  31. PHYSICAL EXAMINATION • Lower extremities -Swelling and pitting edema in right lower limb, specially in foot, ankle and distal side of leg -Size difference between circumference of two legs was about 1.5cm. -Two skin lesions (brownish colored pigmentation with 3 * 3mm in size )were visible on lateral side of the right leg (scars of pseudofolliculitis). Bilateral dorsalispedisand posterior tibialis arteries pulsation were palpable, normal and symmetric. -Active and passive motion of joints were normal. -Force of proximal and distal muscles were normal .

  32. DUPPLER SONOGRAPHY • Thrombosis in popliteal vein • CFV and SFV were normal. • SMA, SMV, portal vein and IVC were normal.

  33. DIAGNOSIS DVT

  34. LABORATORY TEST • CBC WBC:7400 RBC:5180000 HG:14.3 HCT:45 MCV:87 MCH:28 MCHC:32.1 Plat:374000 • Biochemistry BS:207 Urea:31 Creat:1 AST:14 ALT:13 Al Ph:234 Bil Total:0.75 Bil Direct:0.16 Uric acid:4.8

  35. LABORATORY TEST • Electrolyte Na:137 K:4.2 Ca:9.2 P:3.5 • Coagulative PTT:31 PT:13 INR:1.1

  36. Pathergy test

  37. THIRD CASE 34 years old male

  38. HISTORY -Diplopia and visual loss since Farvardin, 1390 due to thrombosis of cerebral venous sinuses, increase of ICP and optic disk atrophy. -8 months, ago he had DVT in left lower limb for which Warfarin started. -Post prandial abdominal pain 6 months, ago

  39. HISTORY -Abdomino-pelvice CT scan: vascular aneurysm was suspected. -CT Angiography showed aneurysm in abdominal aorta and right common iliac artery. -Operation was done and Prednisolone,60mg daily and Cyclophosphamide, monthly were started.

  40. HISTORY • Review of system -Oral aphthous since the age of eight -No history of genital lesions -No history of erythema nodozum or pseudofolliculitis -No history of arthritis

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